Provider Demographics
NPI:1679759146
Name:CLARK, MELINDA PACE (LCSW)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:PACE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:LEE
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:309 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-2421
Mailing Address - Country:US
Mailing Address - Phone:256-259-5313
Mailing Address - Fax:256-259-4923
Practice Address - Street 1:70 FREEDOM LN
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35769-3763
Practice Address - Country:US
Practice Address - Phone:256-574-5508
Practice Address - Fax:256-259-2727
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1628C101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51545900OtherBCBS